Abstract
BackgroundInnovative and sustainable strategies to strengthen districts and other sub-national health systems and management are urgently required to reduce child mortality. Although highly effective evidence-based and affordable child survival interventions are well-known, at the district level, lack of data, motivation, analytic and planning capacity often impedes prioritization and management weaknesses impede implementation. The Community and District Empowerment for Scale-up (CODES) project is a complex management intervention designed to test whether districts when empowered with data and management tools can prioritize and implement evidence-based child survival interventions equitably.MethodsThe CODES strategy combines management, diagnostic, and evaluation tools to identify and analyze the causes of bottlenecks to implementation, build capacity of district management teams to implement context-specific solutions, and to foster community monitoring and social accountability to increase demand for services. CODES combines UNICEF tools designed to systematize priority setting, allocation of resources and problem solving with Community dialogues based on Citizen Report Cards and U-Reports used to engage and empower communities in monitoring health service provision and to demand for quality services. Implementation and all data collection will be by the districts teams or local Community-based Organizations who will be supported by two local implementing partners. The study will be evaluated as a cluster randomized trial with eight intervention and eight comparison districts over a period of 3 years. Evaluation will focus on differences in uptake of child survival interventions and will follow an intention-to-treat analysis. We will also document and analyze experiences in implementation including changes in management practices.DiscussionBy increasing the District Health Management Teams’ capacity to prioritize and implement context-specific solutions, and empowering communities to become active partners in service delivery, coverage of child survival interventions will increase. Lessons learned on strengthening district-level managerial capacities and mechanisms for community monitoring may have implications, not only in Uganda but also in other similar settings, especially with regard to accelerating effective coverage of key child survival interventions using locally available resources.Trial registration numberISRCTN15705788, Date of registration; 24 July 2015.
Highlights
Innovative and sustainable strategies to strengthen districts and other sub-national health systems and management are urgently required to reduce child mortality
Lessons learned on strengthening district-level managerial capacities and mechanisms for community monitoring may have implications, in Uganda and in other similar settings, especially with regard to accelerating effective coverage of key child survival interventions using locally available resources
The weak support for implementation of interventions at the district level is attributed to factors such as poor management capacity, including the lack of local abilities and local data to prioritize and contextualize interventions, insufficient emphasis on results, lack of identification of health system bottlenecks to effective coverage, lack of needs-based financing and resources allocation to carry out contextspecific managerial solutions and lack of financial decision-making space to carry out context-specific managerial solutions, and failure to involve communities as active proponents in helping overcome obstacles to high coverage [3,4,5]
Summary
Trial design This is being implemented as a cluster randomized controlled trial with eight districts (clusters) as intervention and eight other districts as comparison districts. Treat children who are ill with malaria, pneumonia and diarrhea with appropriate treatment
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